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Inpatient Rehabilitation Facility PPS

IRF Classification Criteria

  • Reporting of the Compliance Percentage

    In order to be classified as an inpatient rehabilitation facility a facility must meet the requirements specified in Title 42 Code of Federal Regulations (CFR) 412.23(b)(2), as well as other regulatory requirements. Specifically, a facility's cost reporting period determines the percentage of the facility's total inpatient population that must meet at least one of the medical conditions listed in Title 42 CFR 412.23(b)(2)(iii). Data from a predetermined period of time, which is termed the compliance review period, is used to calculate the percentage of the facility's total inpatient population that met one of the listed medical conditions. In accordance with the program transmittals which CMS issued, the fiscal intermediary (FI) determines the percentage of the facility's total inpatient population that during a compliance review time period met at least one of the medical conditions listed in Title 42 CFR 412.23(b)(2)(iii). By the 15th day of the month the FI will send a report to CMS which identifies the compliance percentage that a facility met during a compliance review time period. The FI will e-mail the report to: CMSComplianceData@cms.hhs.gov and the CMS Regional Office which oversees the geographic area in which the facility is located, as well as the FI's Consortium Contractor Management Officer. The compliance workbooks below each contain a worksheet that the FI will use to report a facility's compliance percentage as well as other identifying information. The appropriate worksheet that the FI will use to report the data is dependent on the instructions in CMS' program transmittals. Each workbook also has an example of a completed worksheet, and a worksheet describing how the data should be formatted. The FI should only submit the worksheet that the FI has completed with data not the entire workbook.
  • Compliance Worksheets To Use To Report The Compliance Data

    The FI will use the compliance worksheet in compliance workbook A if the data being reported for a facility is only one compliance percentage, and if in accordance with CMS's program transmittals the compliance review period is not partitioned into two portions of time. The FI will use the compliance worksheet in compliance workbook B if the data being reported for a facility is two compliance percentages, and if in accordance with CMS's program transmittals the compliance review period is partitioned into two portions of time.
  • Determining IRF "75% Rule" Compliance

    CMS has established procedures whereby Regional Offices and Fiscal Intermediaries determine whether facilities qualify as Inpatient Rehabilitation Facilities (IRFs). This determination is made on an annual basis at the beginning of each facility's cost reporting period and remains in effect for the duration of that cost reporting period. The "75% rule" is one criterion that is used to determine if a facility may be classified as an IRF. Application of this rule involves a number of steps that are detailed in a document that has been prepared to assist software developers and others who wish to replicate CMS's procedures. This document can be downloaded below in PDF format. Three appendices to the document contain tables that may be useful to programmers. For convenience, these three tables can be downloaded below in Excel format. These three Excel documents are identical to the appendices that are contained in the specifications document.

    Update: November 2, 2006

    An initial version of the specifications was released on September 26, 2006. That version contained several errors in Appendix C. A new version of the specifications is now available below with a corrected version of Appendix C. The following changes were made to Appendix C:

    The following ICD-9-CM code was deleted from Appendix C:
         • 066.4

    The following ICD-9-CM codes were added to Appendix C:
         • 359.81
         • 359.89
         • 852.29

    In addition, one code (438.40) was out of order in the earlier version and was moved so that the list is in the proper sort order.

    No other changes were made to the specifications

    IRF Compliance Rule Specification Files for Download

File

Description

Determining IRF compliance 2006-11-02.pdf

Detailed specifications, including Appendix A, B, and C.

Appendix A 2006-11-02.xls

Appendix A in Excel format.

Appendix B 2006-11-02.xls

Appendix B in Excel format.

Appendix C 2006-11-02.xls

Appendix C in Excel format.

 

Update: October 1, 2007

The November 2, 2006 version of the specifications has been updated.  On October 21, 2007, the updated specifications will be used to determine the compliance percentage.  The new version of the specifications is now available below and it contains a number of corrections and additions.  The following changes were made to Appendix B and Appendix C in the new version:

Changes made to Appendix B:

  • Row 8 (impairment group 0002.1). Changed order of diagnosis codes in Columns C, D, and E so they are in numeric order (no change made to the actual codes listed).
  • Rows 15 through 23 (impairment groups 0004.110 through 0004.130).  Replaced diagnosis code "724.0x" in Column D with diagnosis codes listed in Columns D through G.  The purpose of this change is to explicitly list the diagnosis codes implied by "740.0x".  This change was made for clarity.  There is no change in the actual exclusion diagnosis codes.
  • Rows 24 through 32 (impairment groups 0004.210 through 0004.230).  Deleted diagnosis codes 953.6 and 953.7 in Columns I and J.  These are not valid diagnosis codes, but were listed in error in previous versions.  Diagnosis code 953.8 was moved to Column I to fill in the space left by the deleted codes.
  • Rows 53 through 55 (impairment groups codes 0014.1, 0014.2, and 0014.3).  Added diagnosis codes in Columns C through G: 808.2, 808.3, 808.59, 808.8, and 808.9.  These codes were omitted in error in previous versions.

Changes made to Appendix C:

  • Codes were added.  Nine of these codes have start dates of 10/01/2007 meaning that they apply only to assessment records with a discharge date (Item 40) that is on or after 10/01/2007.
  • 220 ICD-9-CM codes were deleted.  These ICD-9-CM codes were listed in previous versions, but are not valid ICD-9-CM codes.  Therefore, they were deleted from Appendix C.
  • Appendix C has a new tab ("Added and deleted codes") that lists the codes that were added and deleted.

IRF Compliance Rule Specification Files for Download

File

Description

Determining IRF compliance 2007-10-01.pdf

Detailed specifications, including Appendix A, B, and C.

Appendix A 2007-10-01.xls

Appendix A in Excel format.

Appendix B 2007-10-01.xls

Appendix B in Excel format.

Appendix C 2007-10-01.xls

Appendix C in Excel format.

 

 

Downloads

Workbook A - one compliance percentage for one portion of time [ZIP, 6kb]

Workbook B - two compliance percentages for two portions of time [ZIP, 14kb]

IRF Compliance Rule Specification Files [ZIP, 138kb]

October 1, 2007 IRF Compliance Rule Specification Files [Zip, 203kb]

Related Links Inside CMS

IRF Survey and Certification

Regional Office Contacts
Related Links Outside CMS

Case Mix Certification Rule for Inpatient Rehabilitation Facilities, by the RAND Corp.

 

Page Last Modified: 08/26/2008 12:48:55 PM
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